| Mellow Jac | |
|
108 Lilac Dr Kissimmee FL 34743-6345 | |
| (407) 734-3417 | |
| Not Available |
| Full Name | Mellow Jac |
|---|---|
| Speciality | Community/behavioral Health |
| Location | 108 Lilac Dr, Kissimmee, Florida |
| Authorized Official Name and Position | Amie Pereira (AUTHORIZED MEMBER) |
| Authorized Official Contact | 4076150448 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Mellow Jac 108 Lilac Dr Kissimmee FL 34743-6345 Ph: (407) 734-3417 | Mellow Jac 108 Lilac Dr Kissimmee FL 34743-6345 Ph: (407) 734-3417 |
| NPI Number | 1396348082 |
|---|---|
| Provider Enumeration Date | 11/17/2020 |
| Last Update Date | 11/17/2020 |
| Certification Date | 11/17/2020 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1396348082 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103K00000X | Behavior Analyst | (* (Not Available)) | Secondary |
| 251S00000X | Community/behavioral Health | (* (Not Available)) | Primary |
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